Thank you for contacting us.   This is the last of the information that is necessary to complete your enrollment with our agency.  

Please review the enclosed information and complete the last page of information.  Proof of family income and residency is required for enrollment into our sliding fee program.  If you do not provide this information you will not be eligible for the sliding fee.  

Should you have any questions while completing this information, please contact us at 440-285-3568 X303

Our Copeline is available 24 hours a day, 7 days a week for any mental health crisis.   Copeline can be reached at 888-285-5665

As a provider of health services, Ravenwood Mental Health Center is legally obligated to follow regulations as it relates to the Health Insurance Portability and Accountability Act (HIPAA). This legislation outlines ways in which we may communicate your protected health information to other business associates, professionals, and service providers for the purposes of your health treatment, payment of services, and other healthcare operations. A copy of the agency Privacy Notice has been given to you, describing ways in which RMHC may, or may not divulge protected health information for these purposes.

The minimum amount of your protected health information necessary to carry out healthcare treatment, payment and health care operations will be released to outside entities. Business Associates and other healthcare providers are required, as well, to treat your protected health information with confidentiality under the HIPAA standards.

Ravenwood Mental Health Center reserves the right to change its privacy practices retroactively, and that the terms of the agency Privacy Notice may change. Any revisions in changed privacy practices can be obtained through contacting the Privacy Officer at this agency.

You have a right to request restrictions on how protected health information is used or disclosed to carry out your healthcare treatment, payment or healthcare operations. Ravenwood is not required to agree to those restrictions, but if Ravenwood does, those restrictions will be binding.

You have the right to revoke this document, in writing, except to the extent that Ravenwood Mental Health Center has taken action in the reliance on the consent. Otherwise this consent will remain valid for six years from the date of its creation.

Consumer signature: My signature on the acknowledgment verifies that I have received the agency's Notice of Privacy Practices, and I understand how my protected health information may be used for the purpose of treatment, payment, and/or healthcare operations.

Billing Authorization/Disclosure Statement
Member Enrollment

To be eligible to receive public funds to help pay for the cost of your mental health and/or substance use disorder services, you will need to read and sign this statement that allows the agency to give billing information to the Geauga County Board of MHRS. Starting November 1, 2016, all agencies in the Geauga County Board of MHRS Board network will change how they submit billing and receive payment from the Geauga County Board of Mental Health and Recovery Services. 

Agencies will use a uniform sliding fee scale based on the federal poverty guidelines to determine what, if anything, you may need to pay for services. If you do not currently have insurance or Medicaid benefits, an agency staff member can assist you with a Thorough Benefit Evaluation (TBE). This may include applying for Medicaid benefits or accessing the www.healthcare.gov website to help you apply for health insurance coverage.

If you are eligible for Medicaid or other public funds, then the agency will submit billing information, such as your name and social security number to the Geauga County MHRS Board. The Board will:

• Enroll you in the Geauga County Plan or State Medicaid Plan and
• Determine what public funds can be used to pay for your services, and
• Pay the agency through an information system that communicates with Ohio Department Job and Family Services for possible Medicaid eligibility purposes.

ALL INFORMATION COLLECTED WILL BE KEPT CONFIDENTIAL, consistent with state and federal law, including, but not limited to compliance with the HIPAA Privacy Act and the 42 CFR. Name identified information will only be used to pay for services received. Other information will be kept without your name attached and will be stored by a unique number. You have the right to review your records and notify the provider of errors in the record. Billing information will be kept for a minimum of six years after you have received services, and only demographic information will be kept after that time.

Geauga County residents will have 60 days from the date of this disclosure to participate in the TBE, either with an agency staff member or independently. Refusal or lack of proof to attempt to enroll in either of the above stated insurance/benefit plans will result in 100% full fee to the client/guardian for future services rendered. The agency may not be able to provide services after 11/1/2016 if you do not agree to allow the board to determine if you are eligible for public funds. If you have any questions please discuss them with the Financial Registration Department.

Geauga County Board of Mental Health and Recovery Services
NOTICE OF PRIVACY PRACTICES
Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact:
Privacy Officer, 440-285-2282

OUR DUTIES

At the Geauga County Board of Mental Health and Recovery Services, we are committed to protecting your health information and safeguarding that information against unauthorized use or disclosure. This Notice will tell you how we may use and disclose your health information. It also describes your rights and the obligations we have regarding the use and disclosure of your health information.

We are required by law to: 1) maintain the privacy of your health information; 2) provide you Notice of our legal duties and privacy practices with respect to your health information; 3) to abide by the terms of the Notice that is currently in effect; and 4) to notify you if there is a breach of your unsecured health information. 

HOW WE MAY USE AND DISCLOSE YOUR PERSONAL HEALTH INFORMATION
When you receive services paid for in full or part by the Board, we receive health information about you. We may receive, use or share that health information for such activities as payment for services provided to you, conducting our internal health care operations, communicating with your healthcare providers about your treatment and for other purposes permitted or required by law. The following are examples of the types of uses and disclosures of your personal information that we are permitted to make:

Payment - We may use or disclose information about the services provided to you and payment for those services for payment activities such as confirming your eligibility, obtaining payment for services, managing your claims, utilization review activities and processing of health care data.

Health Care Operations - We may use your health information to train staff, manage costs, conduct quality review activities, perform required business duties, and improve our services and business operations.

Treatment -We do not provide treatment, but we may share your personal health information with your health care providers to assist in coordinating your care.

Other Uses and Disclosures -We may also use or disclose your personal health information for the following reasons as permitted or required by applicable law: To alert proper authorities if we reasonably believe that you may be a victim of abuse, neglect, domestic violence or other crimes; to reduce or prevent threats to public health and safety; for health oversight activities such as evaluations, investigations, audits, and inspections; to governmental agencies that monitor your services; for lawsuits and similar proceedings; for public health purposes such as to prevent the spread of a communicable disease; for certain approved research purposes; for law enforcement reasons if required by law or in regards to a crime or suspect; to correctional institutions in regards to inmates; to coroners, medical examiners and funeral directors (for decedents); as required by law; for organ and tissue donation; for specialized government functions such as military and veterans activities, national security and intelligence purposes, and protection of the President; for Workers’ Compensation purposes; for the management and coordination of public benefits programs; to respond to requests from the U.S. Department of Health and Human Services; and for us to receive assistance from consultants that have signed an agreement requiring them to maintain the confidentiality of your personal information. Also, if you have a guardian or a power of attorney, we are permitted to provide information to your guardian or attorney in fact.

Uses and Disclosures That Require Your Permission
We are prohibited from selling your personal information, such as to a company that wants your information in order to contact you about their services, without your written permission.

We are prohibited from using or disclosing your personal information for marketing purposes, such as to promote our services without your written permission.

All other uses and disclosures of your health information not described in this Notice will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the purposes state in your written permission except for those that we have already made prior to your revoking that permission. 

Prohibited Uses and Disclosures
If we use or disclose your health information for underwriting purposes, we are prohibited from using and disclosing the genetic information in your health information for such purposes.

POTENTIAL IMPACT OF OTHER APPLICABLE LAWS
If any state or federal privacy laws require us to provide you with more privacy protections than those explained here, then we must also follow that law. For example, drug and alcohol treatment records generally receive greater protections under federal law. 

YOUR RIGHTS REGARDING YOUR PERSONAL HEALTH INFORMATION
You have the following rights regarding your health information:

• Right to Request Restrictions. You have the right to request that we restrict the information we use or disclose about you for purposes of treatment, payment, health care operations and informing individuals involved in your care about your care or payment for that care. We will consider all requests for restrictions carefully but are not required to agree to any requested restrictions.*

• Right to Request Confidential Communications. You have the right to request that when we need to communicate with you, we do so in a certain way or at a certain location. For example, you can request that we only contact you by mail or at a certain phone number. 

• Right to Inspect and Copy. You have the right to request access to certain health information we have about you. Fees may apply to copied information.*

• Right to Amend. You have the right to request corrections or additions to certain health information we have about you. You must provide us with your reasons for requesting the change.*

• Right to An Accounting of Disclosures. You have the right to request an accounting of the disclosures we make of your health information, except for those made with your permission and those related to treatment, payment, our health care operations, and certain other purposes. Your request must include a time frame for the accounting, which must be within the six years prior to your request. The first accounting is free but a fee will apply if more than one request is made in a 12-month period.*

• Right to a Paper Copy of Notice. You have the right to receive a paper copy of this Notice. This Notice is also available at our web site www.geauga.orgbutyou may obtain a paper copy by contacting the Board Office.

To exercise any of the rights described in this paragraph, please contact the Board Privacy Officer
13244 Ravenna Road, Chardon, OH. 44024 
(440) 285-2282

* To exercise rights marked with a star (*), your request must be made in writing. 
Please contact us if you need assistance.

CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of our current Notice at our officeand on our website at: www.geauga.org. In addition, each time there is a change to our Notice, you will receive information about the revised Notice and how you can obtain a copy of it. The effective date of each Notice is listed on the first page in the top center. 

TO FILE A COMPLAINT
If you believe your privacy rights have been violated, you may file a complaint with the Board or with the Secretary of the Department of Health and Human Services. To file a complaint with the Board, contact the Privacy Officer at the address above. You will not be retaliated against for filing a complaint. If you wish to file a complaint with the Secretary you may send the complaint to:
Office for Civil Rights
U.S. Department of Health and Human Services
Attn: Regional Manager
233 N. Michigan Ave., Suite 240
Chicago, IL 60601